Skinsafe1 is a computer-assisted learning (CAL) program developed to educate patients on melanoma risk factors, melanoma symptoms, and the importance of sun-protective behavior. The program asks users to complete in a single sitting (<30 minutes) computerized modules containing a combination of interactive and didactic segments.1,2 We sought to determine if interactive CAL patient education delivered through Skinsafe, used as a part of a multimodal patient education program, could influence use of sun-protective clothing and sunscreen.

METHODS

This interventional study was approved by the institutional review board and conducted at University Hospitals Case Medical Center. Any individuals presenting to the dermatology clinic lobby, spoke English, and were at least 18 years old were eligible. At enrollment, participants were randomized into the control or intervention arm using permutated block randomization. The intervention group completed a multimodal education program that included the following components: (1) the CAL Skinsafe tutorial; (2) a skin self-examination tutorial while clothed, under the guidance of clinicians; and (3) a self-selected telecommunication reminder (phone call, text message, e-mail, or letter) to receive monthly for 12 weeks, which reminded the participant to perform skin self-examinations. All participants received a melanoma brochure, a common form of patient education distributed in dermatology clinics.

Survey data were collected on the day of enrollment and 3 months after enrollment, at the conclusion of the study. The data collected included demographic information and self-reported use of sun-protective clothing (ie, wide-brimmed hat, long-sleeved shirts) and sunscreen.

A logistic regression was used to analyze the data. We constructed 2 models controlling for sex, age, race, education, and family history of melanoma.

RESULTS

A total of 132 participants completed the study. At baseline, participants in the control and intervention groups were similar in terms of sex, age, race, and education level. There was no significant difference in response rate in the intervention and control groups (P = .77).

At baseline, 34.7% reported “always” or “frequently” using sun-protective clothing, and 39.1% reported “always” or “frequently” using sunscreen. Those in the intervention group were 2.4 times more likely to wear sun-protective clothing at the end of the study (odds ratio [OR], 2.4 [95% CI, 1.09-5.29]) (Table). Those in the intervention group were also more likely use sunscreen, but this was not statistically significant in our analysis (OR, 1.26 [95% CI, 0.58-2.77]). Men were less likely to use sunscreen (OR, 0.32 [95% CI, 0.14-0.72]) (Table).

COMMENT

The CAL Skinsafe education system, when used as a part of a multimodal patient education program, was successful at increasing sun-protective clothing use. We suspect that this is attributable to the education supplied during the CAL Skinsafe tutorial, which emphasizes the importance of UV protection in 2 separate modules. Of note, moderate increases in performance in sunscreen use occurred in both groups at the 3-month follow-up, and we believe that subjects may have been more inclined to engage in sun-protective behaviors in the months after visiting a dermatologist's office. Men were less likely to use sunscreen—perhaps because they do not use topical products as frequently as women. Other studies have also noted sunscreen use and other sun-protective behaviors to be greater in women.3,4

It is unclear why the intervention had a greater effect on sun-protective clothing use rather than sunscreen use. We hypothesize that purchasing and applying sunscreen at least 20 minutes before engaging in outdoor activities (as directed in the Skinsafe modules) is more cumbersome than donning sun-protective clothing. Many dermatologists frequently remind patients of the importance of sunscreen use—our findings suggest that perhaps sun-protection education in the office can be improved by encouraging patients to regularly use sun-protective clothing as well as sunscreen.

There are several limitations to our study. Primarily, all outcomes measured relied on self-reported behavior. In addition, we have to consider the Hawthorne effect, whereby subjects modify their behavior in response to being studied. Alternatively, participants might have been dishonest in follow-up surveys because they knew the aim of our intervention. Furthermore, all of the subjects in the intervention group received all 3 aspects of the multimodal educational program (CAL Skinsafe program, skin self-examination tutorial, and telecommunication reminders to perform skin self-examinations), but only the CAL Skinsafe program emphasized the use of sun-protective clothing and sunscreen. Therefore, it is not clear whether the changes observed are attributable to synergy among the 3 interventions or primarily to the CAL Skinsafe program.

Author Contributions: Ms Aneja and Drs Brimhall, Kast, Carlson, Cooper, and Bordeaux had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Brimhall, Cooper, and Bordeaux. Acquisition of data: Savina Aneja, Brimhall, Kast, and Carlson. Analysis and interpretation of data: Savina Aneja, Brimhall, Sanjay Aneja, Kast, Cooper, and Bordeaux. Drafting of the manuscript: Savina Aneja, and Kast. Critical revision of the manuscript for important intellectual content: Brimhall, Sanjay Aneja, Kast, Carlson, Cooper, and Bordeaux. Statistical analysis: Savina Aneja and Sanjay Aneja. Obtained funding: Cooper. Administrative, technical, and material support: Savina Aneja, Brimhall, Kast, and Cooper. Study supervision: Cooper and Bordeaux.

Financial Disclosure: Dr Bordeaux is supported by the Dermatology Foundation Clinical Career Development Award in Dermatologic Surgery.

Funding/Support: Dr Bordeaux is supported by the Dermatology Foundation Clinical Career Development Award in Dermatologic Surgery. This publication was made possible by the Case Western Reserve University Skin Diseases Research Center Grant Number P30AR039750 from National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Correspondence

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